| NPI | 1962834069 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: PA OEG003640) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX 8293-T) |
| Enumeration Date | 2013-07-31 |
| Last Update Date | 2021-03-22 |